Case Report

Esophagogastric fistula is a rare complication following Nissen fundoplication, with symptoms usually developing within weeks to 3 years postoperatively.1-3 Proposed mechanisms include recalcitrant reflux, erosion of sutures with Teflon pledgets, and damage associated with repeat procedures.1-3 Past reports describe management of the esophagogastric fistulae with anti-reflux medications, dilation of both lumens, and repeat fundoplication.1-3

A barium esophagogram revealed 2 esophagogastric fistulas, moderate reflux into the esophagus, and mild presbyesophagus (Figure 3). The original operative report was not available, but we suspected that Teflon pledgets were used to reinforce the fundoplication during surgery, as was common practice at that time. We believe our patient’s fistula developed as a consequence of constant irritation from pledgets, causing it to erode from the gastric serosa into the esophageal lumen on both sides of the wrap.2

Conservative management with optimized medical therapy for GERD failed, and the patient opted for surgery. The surgical approach included laparoscopic esophageal transection above the wrapped esophagus, Roux-en-Y reconstruction with esophagojejunostomy, and excision of the wrap with attached esophagus. Gastric bypass was selected for this patient due to his obesity and underlying comorbid conditions. The patient had resolution of his symptoms, decrease in body mass index (BMI) from 36.11 kg/m2 to 30.58 kg/m2, and improvement of diabetes and hypertension.